Part 1 · Decisions

Review ledger

Every solution path has a draft decision, made by Claude on the owner's request so the plan could be built. None is reviewed yet. Work through this list top to bottom: the least certain and most consequential picks come first.

Awaiting review

187 / 187

Chosen

144

Low confidence

Flagged for a closer look

How to review

Open a path, read its trade-offs, and tell Claude to keep, flip, or change it.
Flipping a pick can break others: the build checks that every chosen path's requirements are chosen, no two chosen paths conflict, and every problem a chosen path creates has a chosen answer.
Reviewed decisions get reviewed: true in content/paths/decisions.ts and drop off this list.
Chosen paths feed Changes by phase.

1. Flagged for a closer look (36)

Picks with a specific question for you, least confident first.

Path	Decision	Confidence	Why	What to review
Cover all residents regardless of immigration status Immigrants and mixed-status families fall through gaps	Chosen 4. Wave 4: everyone	low	Residence-based eligibility ends emergency-only care and uncompensated costs; a residence period limits migration concerns.	Value judgment with real cost; decide whether undocumented residents are covered.
Cover lawful residents; keep emergency care for others Immigrants and mixed-status families fall through gaps	Rejected	low	Keeps uncompensated emergency care and mixed-status confusion.	The alternative to the pick above.
Use government march-in and compulsory licensing Patent thickets and evergreening delay generics	Rejected	low	Weakens patent certainty; negotiation covers most cases.	Could be kept as a backstop.
Shorter training: combined undergrad/medical programs Medical education debt shapes specialty choice	Rejected	low	Large accreditation change; lower priority.	Could revisit later.
Catastrophic coverage after a waiting period Long-term care requires spending down to poverty	Rejected	low	Full long-term care coverage inside the public plan chosen instead.	Cheaper fallback if the full program is too costly.
Let health budgets pay for housing and food Housing, food, and transportation drive health, but health care isn't designed for them	Chosen 5. Stabilize & govern	low	Lets health budgets pay for housing and food in pilots.	Health systems aren't housing experts; start as pilots.
Single public payer for everyone Tens of millions of people have no coverage	Chosen 1. Enactment & build	medium	Only path that ends churn, networks, job lock, and most admin cost at once; matches the site's cost model.	The biggest call on the site. Weigh against regulated multi-payer (Germany/Switzerland), which keeps plan choice with smaller savings.
Regulated multi-payer: everyone must have a non-profit or tightly regulated plan Tens of millions of people have no coverage	Rejected	medium	Conflicts with single payer; keeps several insurers' overhead.	Reconsider if keeping plan choice matters more than admin savings.
Lower the Medicare age step by step (and enroll children at birth) Tens of millions of people have no coverage	Rejected	medium	Too slow as the main route; the wave roll-out already borrows its age-based sequencing.	Could replace the wave plan if you prefer a slower, measurable expansion.
Automatic enrollment with free default coverage Tens of millions of people have no coverage	Chosen 0. Preparation	medium	Interim: enroll uninsured people in free coverage while the public program is built.	Only a bridge; check it doesn't delay the main transition.
No cost sharing at the point of care Underinsurance: covered, but can't afford to use it	Chosen 1. Enactment & build	medium	Ends underinsurance and new medical debt; the model already assumes it.	Costs the most of the cost-sharing options and raises use; compare with Germany-style income-capped copays.
Modest copays with an income-based annual cap Underinsurance: covered, but can't afford to use it	Rejected	medium	Conflicts with zero cost sharing; keeps billing at the point of care.	The main alternative if zero cost sharing proves too expensive.
Cover the territories in the national program on the same terms as the states U.S. territories get capped, lower federal health funding	Chosen 4. Wave 4: everyone	medium	Universal means every U.S. citizen; the territories join with the last wave.	Higher federal cost (GAO's Puerto Rico estimate implies about 1.6 to 3 times today's federal Medicaid spending there). Parity Medicaid is the smaller alternative.
Replace premiums with progressive taxes Premiums are a large, flat, hidden tax on wages	Chosen 1. Enactment & build	medium	Progressive replacement for flat premiums; required by single payer.	Check the household calculator: households above about $240k pay more.
Public coverage rules with clinician-led review Claim denials	Chosen 1. Enactment & build	medium	One public rulebook with independent appeals.	Moves 'no' to program-wide decisions; see the rationing subpaths.
Eliminate prior authorization except for a short list Prior authorization delays and blocks care	Chosen 2. Wave 1: seniors, near-seniors, and children	medium	Keep prior authorization only for a short list; audit afterwards.	Watch for more low-value care; depends on audit capacity.
Fold Medicare Advantage into the public program Medicare Advantage overpayments and coding intensity	Chosen 2. Wave 1: seniors, near-seniors, and children	medium	Medicare joins the public program in wave one; extra benefits move into the public plan.	MA enrollees lose plans they chose; check dental/vision/hearing are added first.
Cap commercial prices at a multiple of Medicare U.S. prices are far higher than in other countries	Chosen 1. Enactment & build	medium	Caps commercial prices while private plans remain during the waves.	Set the cap level; too low risks closures.
Global budgets for hospitals U.S. prices are far higher than in other countries	Chosen 1. Enactment & build	medium	Hospital budgets end most hospital billing and stabilize rural hospitals.	Main risk is rationing and under-treatment; see the subpaths chosen for those.
Fee-for-service at public fee schedule U.S. prices are far higher than in other countries	Chosen 1. Enactment & build	medium	Physicians and clinics paid per service at a national fee schedule; rewards productivity and short waits.	Encourages volume; compare with capitation for primary care.
Capitation for primary care and integrated systems U.S. prices are far higher than in other countries	Chosen 1. Enactment & build	medium	Optional, as the detailed plan sets out: primary care practices can take a blended per-patient payment, and integrated systems can take a risk-adjusted budget for patients who choose them.	Opt-in only; the fee schedule stays the default. Watch for upcoding and avoiding sick patients.
National negotiation for all drugs Brand-name drug prices far above production cost	Chosen 1. Enactment & build	medium	National negotiation for all drugs, tied to added benefit.	Weigh savings against slower launches and some lost R&D (CBO: about 59 fewer drugs over 30 years for H.R. 3).
Convert to emergency and outpatient centers Rural hospital closures	Chosen 0. Preparation	medium	Lets hospitals that can't sustain inpatient care keep emergency care.	Worsens maternity deserts; paired with maternity standby payments.
Raise primary care pay relative to specialties Physician shortage, especially in primary care	Chosen 1. Enactment & build	medium	Shifts fee-schedule dollars to primary care.	Specialists lose income.
Full practice authority for NPs, PAs, pharmacists, dental therapists Scope-of-practice limits waste capacity	Chosen 0. Preparation	medium	Fastest way to add capacity before demand rises.	Physician groups raise quality concerns; paired with outcome monitoring.
Every person registered with a primary care home Medical errors and poor care coordination	Chosen 4. Wave 4: everyone	medium	Every resident registered with a primary care practice, with self-referral for some specialties.	Gatekeeping limits direct specialist access.
Evidence-based coverage decisions Low-value care and overtreatment	Chosen 1. Enactment & build	medium	Evidence-based coverage decisions.	Controversial; see the rationing subpaths.
Harm reduction services Overdose crisis and gaps in addiction treatment	Chosen 0. Preparation	medium	Fewer deaths; community opposition.	Supervised consumption sites are contested.
Universal long-term care insurance Long-term care requires spending down to poverty	Chosen 2. Wave 1: seniors, near-seniors, and children	medium	Ends spend-down. Funded inside the public plan, as the cost model already assumes: home- and community-based care becomes an entitlement, home health has no asset test, and nursing-home care is covered except room and board.	The model assumes 10–20% more use of home care; the woodwork effect could be larger (Japan's demand grew faster than expected).
Cover dental, vision, and hearing fully Dental, vision, and hearing are mostly uncovered	Chosen 4. Wave 4: everyone	medium	Matches the cost model: adult dental, glasses, and hearing aids covered; only cosmetic dental, orthodontics, and premium eyewear stay out of pocket.	Dentist capacity is limited; the model assumes 35% more dental use. Basic-only coverage is the cheaper fallback.
Cover preventive and basic dental; hearing aids and glasses with limits Dental, vision, and hearing are mostly uncovered	Rejected	medium	Full dental chosen to match the cost model.	The fallback if dental capacity or cost is a problem.
National health record and patient ID Records don't follow patients	Chosen 1. Enactment & build	medium	Records follow patients.	Privacy and security risks; paired with privacy law and redundancy.
Allow supplemental only (non-covered items) Two-tier care: a private fast lane for those who can pay	Chosen 4. Wave 4: everyone	medium	Private insurance only for non-covered extras.	Decide where the line between extras and core care sits.
State pilots first Transition disruption: jobs, companies, and familiar coverage	Rejected	medium	Phased national waves chosen instead.	State pilots could precede wave one if you prefer more evidence first.
A mix of payroll, income, and redirected spending Replacing premiums with taxes	Chosen 1. Enactment & build	medium	Employer payroll tax plus an income-based household premium and recaptured income tax, as in the model.	Check the rates and the $250k payroll exemption.
Maintenance-of-effort payments from states States lose control and budgets shift between levels of government	Chosen 1. Enactment & build	medium	States pay in what they spent on Medicaid.	Locks in historical differences between states.

2. Everything else (151)

Mostly picks that follow from the ones above, or interim fixes. Quick to confirm.

Path	Decision	Confidence	Why	What to review
Prize funds and advance market commitments R&D is funded by high prices, which ties innovation to unaffordability	Chosen 5. Stabilize & govern	low	Start with antibiotics, where markets fail.	—
Keep social programs separate Housing, food, and transportation drive health, but health care isn't designed for them	Rejected	low	Health-budget pilots chosen instead.	—
Salaried clinicians in public or non-profit groups Paying a fixed amount per patient rewards doing less	Rejected	low	Fee schedule chosen for clinicians.	—
Require timely U.S. launch as a condition of market access Price limits can cause shortages, launch delays, or exits	Rejected	low	Hard to enforce.	—
Value-based cost sharing Underinsurance: covered, but can't afford to use it	Rejected	medium	Keeps billing; the coverage-list path handles low-value care instead.	—
Give the territories state-like Medicaid funding but keep separate programs U.S. territories get capped, lower federal health funding	Rejected	medium	Full inclusion chosen; parity would keep coverage tied to territory Medicaid eligibility.	—
Restore competition and leave prices to markets U.S. prices are far higher than in other countries	Rejected	medium	Too slow as the main price tool; antitrust is still chosen separately.	—
Limit private equity ownership and require disclosure Private equity roll-ups in medicine	Chosen 0. Preparation	medium	Targets asset stripping and roll-ups.	—
Tie nonprofit tax exemption to community benefit Executive pay and nonprofit status	Chosen 0. Preparation	medium	Ties nonprofit tax exemptions to charity care.	—
Public review of hospital budgets Executive pay and nonprofit status	Chosen 3. Waves 2 & 3: working-age adults	medium	Executive and admin costs reviewed within hospital budgets.	—
International reference pricing Brand-name drug prices far above production cost	Rejected	medium	Negotiation already uses international prices as a benchmark.	—
Public manufacturing of off-patent drugs Brand-name drug prices far above production cost	Chosen 1. Enactment & build	medium	Public or nonprofit production of off-patent drugs with high prices or shortages.	—
Limit patent thickets and evergreening Patent thickets and evergreening delay generics	Chosen 0. Preparation	medium	Limits thickets and pay-for-delay; keeps core patents.	—
Keep the current patent system Patent thickets and evergreening delay generics	Rejected	medium	Thickets keep delaying generics.	—
Expand public R&D funding R&D is funded by high prices, which ties innovation to unaffordability	Chosen 1. Enactment & build	medium	Offsets some lost private R&D with public funding.	—
Value-based prices that reward real innovation R&D is funded by high prices, which ties innovation to unaffordability	Chosen 1. Enactment & build	medium	Pays more for real breakthroughs, less for me-too drugs.	—
National stockpile and onshore production Drug shortages of cheap, essential generics	Chosen 5. Stabilize & govern	medium	Buffer for disruptions.	—
Standby payments to keep labor units open Maternity care deserts	Chosen 2. Wave 1: seniors, near-seniors, and children	medium	Keeps rural labor units open.	—
Expand midwives and birth centers Maternity care deserts	Chosen 0. Preparation	medium	Adds capacity in maternity deserts.	—
Higher pay in shortage areas Health professional shortage areas	Chosen 1. Enactment & build	medium	Simple add-on to the fee schedule.	—
Publicly funded EMS as essential service Getting to care: transportation and ambulances	Chosen 3. Waves 2 & 3: working-age adults	medium	EMS funded by budget like fire departments.	—
Easier licensing for foreign-trained physicians Physician shortage, especially in primary care	Chosen 0. Preparation	medium	Fast supply increase under supervision.	—
Tuition-free medical and nursing school Medical education debt shapes specialty choice	Chosen 0. Preparation	medium	Tuition-free medical and nursing school tied to service.	—
Minimum nurse staffing ratios Nursing and direct-care shortages and burnout	Chosen 5. Stabilize & govern	medium	Phased in once the pipeline grows.	—
Fund scribes and AI documentation Clinician burnout from paperwork and EHR work	Chosen 0. Preparation	medium	Quick relief now.	—
Team-based care with physician oversight Scope-of-practice limits waste capacity	Rejected	medium	Supervision is a bottleneck in rural areas; full scope chosen instead.	—
Invest outside health care Worse outcomes than peer countries despite the highest spending	Chosen 5. Stabilize & govern	medium	Addresses causes outside health care.	—
Equity-adjusted funding Racial, income, and geographic disparities	Chosen 1. Enactment & build	medium	Extra pay for deprived areas.	—
No-fault compensation for medical injury Malpractice system: slow, costly, and drives defensive medicine	Chosen 5. Stabilize & govern	medium	Faster compensation, less defensive medicine.	—
Safe harbor for following clinical guidelines Malpractice system: slow, costly, and drives defensive medicine	Rejected	medium	No-fault chosen instead.	—
Redeploy billing staff to care coordination Simplifying billing would displace hundreds of thousands of workers	Chosen 1. Enactment & build	medium	Keeps some experienced staff in navigation roles.	—
Feedback and clinician nudges Low-value care and overtreatment	Chosen 5. Stabilize & govern	medium	Cheap feedback to clinicians.	—
Stepped care and integration into primary care Mental health care is hard to get	Chosen 0. Preparation	medium	Large capacity at low cost.	—
Keep means testing, but expand home care Long-term care requires spending down to poverty	Chosen 0. Preparation	medium	Ends home-care waitlists now.	—
Minimum staffing and financial transparency Nursing home understaffing and quality	Chosen 5. Stabilize & govern	medium	Phased staffing minimums with funding in rates.	—
Shift to small homes and home care Nursing home understaffing and quality	Chosen 5. Stabilize & govern	medium	Better quality of life over time.	—
Require non-profit hospice Hospice growth, for-profit entry, and fraud	Rejected	medium	Oversight first; capacity loss risk.	—
Opt-out of national record sharing Health privacy	Chosen 1. Enactment & build	medium	Choice for patients.	—
Legal wait-time guarantees Longer waits if demand grows faster than capacity	Chosen 4. Wave 4: everyone	medium	Legal maximum waits with care elsewhere when missed.	—
Pay for activity on top of budgets Longer waits if demand grows faster than capacity	Chosen 3. Waves 2 & 3: working-age adults	medium	Pays for extra volume on top of budgets.	—
Allow private insurance for covered services Two-tier care: a private fast lane for those who can pay	Rejected	medium	Conflicts with banning duplicate private insurance.	—
Ban duplicate private insurance Two-tier care: a private fast lane for those who can pay	Rejected	medium	Supplemental-only chosen as the middle ground.	—
Dedicated trust fund with automatic indexing Chronic underfunding by government budgets	Chosen 1. Enactment & build	medium	Earmarked revenue indexed to costs.	—
Annual appropriations from general revenue Chronic underfunding by government budgets	Rejected	medium	Conflicts with the trust fund; underfunding risk.	—
Spending-growth target tied to GDP, reviewed publicly Chronic underfunding by government budgets	Chosen 5. Stabilize & govern	medium	Independent board with a growth target.	—
Separate public capital budget, planned regionally Under-investment in equipment and facilities	Chosen 1. Enactment & build	medium	Regional capital planning.	—
Build a capital allowance into rates Under-investment in equipment and facilities	Rejected	medium	Separate capital budget chosen.	—
Cover new treatments at launch, then reassess Slower access to new drugs and technology	Chosen 1. Enactment & build	medium	Cover new drugs at launch, reassess later.	—
Recycle part of drug savings into research Slower access to new drugs and technology	Chosen 1. Enactment & build	medium	Recycle part of drug savings into research.	—
Accept somewhat slower adoption Slower access to new drugs and technology	Rejected	medium	Fast-track coverage chosen instead.	—
Strict opt-out rules for cash-only practice Providers leave, retire, or go cash-only if pay drops	Chosen 1. Enactment & build	medium	Opted-out clinicians stay out for a set period.	—
Lower costs for clinicians, not only pay Providers leave, retire, or go cash-only if pay drops	Chosen 5. Stabilize & govern	medium	Lower clinicians' costs, not just pay.	—
Fast transition in one or two years Transition disruption: jobs, companies, and familiar coverage	Rejected	medium	Too risky at U.S. scale.	—
Regional administrators under national rules One payer becomes one target	Chosen 1. Enactment & build	medium	Regional administrators under national rules.	—
Private supplemental plans for extras Losing the choice of health plan and insurer competition	Chosen 4. Wave 4: everyone	medium	Supplemental plans for extras.	—
Let people choose among public care organizations Losing the choice of health plan and insurer competition	Chosen 3. Waves 2 & 3: working-age adults	medium	Integrated systems (Kaiser/Geisinger style) can enroll patients who choose them, as in the detailed plan.	—
Payroll tax (employer and employee) Replacing premiums with taxes	Rejected	medium	Mix chosen.	—
Progressive income tax (including capital income) Replacing premiums with taxes	Rejected	medium	Mix chosen.	—
Value-added tax Replacing premiums with taxes	Rejected	medium	Regressive without rebates; mix chosen.	—
No employer tax: fund from households directly Employer health taxes can lower wages at firms that never offered coverage	Rejected	medium	Requires household-only financing; the model keeps an employer tax.	—
Automatic exemptions and annual collection through taxes Copays keep billing systems alive and still deter poorer patients	Chosen 4. Wave 4: everyone	medium	Applies only to standby copays (if activated) and to supplemental plans.	—
Drop point-of-care charges entirely Copays keep billing systems alive and still deter poorer patients	Chosen 1. Enactment & build	medium	No charges for core covered care.	—
Only flat, small charges on a few services Copays keep billing systems alive and still deter poorer patients	Rejected	medium	Zero cost sharing chosen.	—
Cover everything clinically effective, without cost thresholds Central coverage decisions can feel like rationing	Rejected	medium	Conflicts with evidence-based coverage.	—
Base budget plus activity payments Fixed budgets can ration care	Chosen 3. Waves 2 & 3: working-age adults	medium	Activity payments on top of budgets.	—
Waiting-time guarantees as a backstop Fixed budgets can ration care	Chosen 4. Wave 4: everyone	medium	Wait guarantees as a backstop.	—
Risk adjustment plus outcome monitoring Paying a fixed amount per patient rewards doing less	Chosen 3. Waves 2 & 3: working-age adults	medium	Outcome monitoring for budget-funded hospitals.	—
Keep private R&D for most drugs; public funds fill gaps Government chooses which research gets funded	Rejected	medium	Public R&D expanded beyond gap-filling.	—
Supervised transition period before independence Quality concerns when non-physicians practice independently	Chosen 0. Preparation	medium	Supervised hours before independence.	—
Hardship waivers for shortage areas Staffing mandates raise costs and may close facilities	Chosen 5. Stabilize & govern	medium	Time-limited waivers for shortage areas.	—
Cash benefit option for family caregivers Covering long-term care can pull unpaid family care into the paid system	Chosen 5. Stabilize & govern	medium	Cash option for family caregivers.	—
Residence period before eligibility Covering all residents raises cost and migration concerns	Chosen 4. Wave 4: everyone	medium	Residence period; emergencies, children, pregnancy covered immediately.	—
Cover from day one Covering all residents raises cost and migration concerns	Rejected	medium	Residence period chosen.	—
Report measures publicly without tying pay to them Targets and quality metrics invite gaming	Rejected	medium	Some pay-for-performance kept (wait guarantees, risk adjustment).	—
States administer under national rules States lose control and budgets shift between levels of government	Chosen 1. Enactment & build	medium	States run enrollment and provider relations under national rules.	—
Public option alongside private insurance Tens of millions of people have no coverage	Rejected	high	Conflicts with single payer; universal only with auto-enrollment.	—
Individual mandate with larger subsidies Tens of millions of people have no coverage	Rejected	high	Conflicts with single payer; penalties fall on low-income people.	—
Continuous eligibility (12-month or multi-year) in Medicaid and CHIP People lose coverage when their life changes (churn)	Chosen 0. Preparation	high	Cheap interim fix for Medicaid churn before the transition.	—
Coverage tied to residence, not job or income People lose coverage when their life changes (churn)	Chosen 4. Wave 4: everyone	high	Follows from residence-based coverage.	—
Decouple coverage from employment Job lock: people stay in jobs to keep insurance	Chosen 4. Wave 4: everyone	high	Follows from single payer.	—
Keep employer insurance but make it portable Job lock: people stay in jobs to keep insurance	Rejected	high	Unneeded once coverage is decoupled from jobs.	—
Every licensed provider is in-network Narrow networks and out-of-network surprises	Chosen 2. Wave 1: seniors, near-seniors, and children	high	Follows from one payer and one rate.	—
Stronger network adequacy rules and audited directories Narrow networks and out-of-network surprises	Rejected	high	Unneeded once networks end.	—
Keep capped funding but raise it and index it to costs U.S. territories get capped, lower federal health funding	Rejected	high	Keeps territory residents on different terms.	—
Buy and cancel existing medical debt Medical debt affects about 100 million people	Chosen 0. Preparation	high	Cheap per dollar forgiven; immediate relief.	—
Ban medical debt from credit reports and limit collections Medical debt affects about 100 million people	Chosen 0. Preparation	high	Low cost; protects credit while old debt winds down.	—
Prevent new debt by ending point-of-care bills Medical debt affects about 100 million people	Chosen 2. Wave 1: seniors, near-seniors, and children	high	Follows from zero cost sharing.	—
Income-based premiums in a multi-payer system Premiums are a large, flat, hidden tax on wages	Rejected	high	Requires a multi-payer system, which was rejected.	—
One public price list for every service Patients can't know prices in advance	Chosen 1. Enactment & build	high	Follows from all-payer rates.	—
Enforce price transparency rules Patients can't know prices in advance	Chosen 0. Preparation	high	Interim enforcement until one price list exists.	—
Set a default out-of-network rate instead of arbitration Surprise billing and a runaway arbitration system	Chosen 0. Preparation	high	Interim: ends arbitration costs before networks disappear.	—
Eliminate out-of-network status Surprise billing and a runaway arbitration system	Chosen 4. Wave 4: everyone	high	Out-of-network ends with one payer.	—
Regulate denials: reporting, penalties, and fast independent appeals Claim denials	Chosen 0. Preparation	high	Interim protection while private plans remain.	—
Gold-carding and automatic approvals Prior authorization delays and blocks care	Chosen 0. Preparation	high	Interim relief for clinicians.	—
Fix Medicare Advantage payments Medicare Advantage overpayments and coding intensity	Chosen 0. Preparation	high	Interim savings until Medicare Advantage is folded in.	—
Public administration with a cost target Insurer overhead and profit	Chosen 1. Enactment & build	high	Follows from single payer; publish an admin-cost target.	—
Tighter medical-loss ratios and non-profit requirement Insurer overhead and profit	Rejected	high	Requires a multi-payer system.	—
Public drug formulary and direct pricing Pharmacy benefit managers profit from opaque drug pricing	Chosen 1. Enactment & build	high	Public formulary and direct pricing replace PBMs.	—
Regulate PBMs: delink pay from drug prices, ban spread pricing Pharmacy benefit managers profit from opaque drug pricing	Chosen 0. Preparation	high	Interim rules until public drug purchasing starts.	—
All-payer rate setting U.S. prices are far higher than in other countries	Chosen 1. Enactment & build	high	One rate for every payer; works during the transition and after.	—
Stronger antitrust: block mergers and undo some Hospital and physician consolidation raises prices	Chosen 0. Preparation	high	Still useful while prices are negotiated.	—
Make consolidation irrelevant to price Hospital and physician consolidation raises prices	Chosen 1. Enactment & build	high	Uniform rates remove the price reason to merge.	—
Remove the profit opportunity through rate setting Private equity roll-ups in medicine	Chosen 1. Enactment & build	high	Uniform rates remove out-of-network arbitrage.	—
Site-neutral payment Facility fees: the same service costs more in a hospital-owned building	Chosen 0. Preparation	high	Same pay for the same service.	—
Ban facility fees for off-campus clinics Facility fees: the same service costs more in a hospital-owned building	Rejected	high	Covered by site-neutral pay.	—
Pay more for reliable supply Drug shortages of cheap, essential generics	Chosen 1. Enactment & build	high	Pays enough to keep essential generics in supply.	—
Fair dispensing fees and support for rural pharmacies Pharmacy closures and pharmacy deserts	Chosen 1. Enactment & build	high	Transparent dispensing fees keep pharmacies open.	—
Mail-order and telepharmacy Pharmacy closures and pharmacy deserts	Chosen 0. Preparation	high	Cheap rural access now.	—
Global budgets for rural hospitals Rural hospital closures	Chosen 2. Wave 1: seniors, near-seniors, and children	high	Stable funding for rural hospitals.	—
Loan forgiveness and service obligations Health professional shortage areas	Chosen 0. Preparation	high	Proven to place clinicians in shortage areas.	—
Permanent telehealth coverage Health professional shortage areas	Chosen 0. Preparation	high	Fast access, especially mental health.	—
Cover ambulance and non-emergency transport Getting to care: transportation and ambulances	Chosen 2. Wave 1: seniors, near-seniors, and children	high	Covers ambulances and rides.	—
Fund more residency slots Physician shortage, especially in primary care	Chosen 0. Preparation	high	Long lead time; start first.	—
Expand nursing schools and faculty pay Nursing and direct-care shortages and burnout	Chosen 0. Preparation	high	Schools turn away qualified applicants today.	—
Cut documentation and billing burden Clinician burnout from paperwork and EHR work	Chosen 4. Wave 4: everyone	high	Simpler billing under one payer.	—
Shift spending toward primary care Worse outcomes than peer countries despite the highest spending	Chosen 1. Enactment & build	high	Primary care spending target.	—
12-month postpartum coverage and home visits High maternal mortality and postpartum coverage gaps	Chosen 0. Preparation	high	Cheap, proven.	—
Hospital safety bundles and review committees High maternal mortality and postpartum coverage gaps	Chosen 0. Preparation	high	Proven in California.	—
Mandatory error reporting and learning system Medical errors and poor care coordination	Chosen 1. Enactment & build	high	No-blame learning system.	—
Rely on universal coverage and uniform rates Racial, income, and geographic disparities	Chosen 1. Enactment & build	high	One rate for every patient.	—
One claims system and standard rules About $1 trillion a year in administrative cost	Chosen 1. Enactment & build	high	One claims system under one payer.	—
Standardize across many payers About $1 trillion a year in administrative cost	Chosen 0. Preparation	high	Interim standardization across today's insurers.	—
Worker transition program Simplifying billing would displace hundreds of thousands of workers	Chosen 1. Enactment & build	high	Mends the main losers of admin savings.	—
Pre-payment analytics and audits Fraud and improper payments	Chosen 1. Enactment & build	high	One data system sees all billing.	—
Stricter provider enrollment Fraud and improper payments	Chosen 1. Enactment & build	high	Stops fraud before payment.	—
Pay mental health clinicians at parity Mental health care is hard to get	Chosen 1. Enactment & build	high	Pays enough that clinicians accept coverage.	—
Easy access to medication treatment Overdose crisis and gaps in addiction treatment	Chosen 0. Preparation	high	Reduces overdose deaths.	—
Tighter hospice oversight Hospice growth, for-profit entry, and fraud	Chosen 0. Preparation	high	Targets fraud.	—
Dedicated public health funding Prevention and public health are underfunded	Chosen 1. Enactment & build	high	Protects public health from cuts.	—
Free preventive care and vaccines Prevention and public health are underfunded	Chosen 0. Preparation	high	Already the rule for ACA preventive services.	—
Mandatory data-sharing standards Records don't follow patients	Chosen 0. Preparation	high	Enforce existing standards now.	—
Mandatory security standards and backup payment systems Cyberattacks can halt payments and care	Chosen 0. Preparation	high	Lesson of the Change Healthcare attack.	—
Redundant public infrastructure Cyberattacks can halt payments and care	Chosen 1. Enactment & build	high	No single point of failure for the national claims system.	—
Strong health privacy law Health privacy	Chosen 0. Preparation	high	Covers apps and data brokers.	—
Build capacity before demand rises Longer waits if demand grows faster than capacity	Chosen 0. Preparation	high	Build capacity before demand rises.	—
Phase rate changes in over several years Providers leave, retire, or go cash-only if pay drops	Chosen 3. Waves 2 & 3: working-age adults	high	Phase rate changes over years.	—
Phased transition in waves Transition disruption: jobs, companies, and familiar coverage	Chosen 0. Preparation	high	Waves over several years; matches the site's draft plan.	—
Fixed budget share for program integrity One payer becomes one target	Chosen 1. Enactment & build	high	Fixed budget for program integrity.	—
Hold the single payer to service standards Losing the choice of health plan and insurer competition	Chosen 5. Stabilize & govern	high	Service standards and an ombudsman.	—
Phase in employer taxes for small and low-wage firms Employer health taxes can lower wages at firms that never offered coverage	Chosen 1. Enactment & build	high	Matches the model's payroll exemption.	—
Independent, transparent coverage body with appeals Central coverage decisions can feel like rationing	Chosen 1. Enactment & build	high	Independent coverage body with appeals.	—
Clinician-led exceptions with fast review Central coverage decisions can feel like rationing	Chosen 1. Enactment & build	high	Fast exceptions for unusual cases.	—
Budgets adjust automatically for population, age, and volume Fixed budgets can ration care	Chosen 3. Waves 2 & 3: working-age adults	high	Budgets follow population and age.	—
Blended payment: part capitation, part fee-for-service Paying a fixed amount per patient rewards doing less	Chosen 1. Enactment & build	high	The primary-care option is blended: per-patient payment for about 70% of expected revenue plus fees for the rest.	—
Price floors and supply guarantees for essential products Price limits can cause shortages, launch delays, or exits	Chosen 1. Enactment & build	high	Protects supply of essentials.	—
Monitor supply and adjust prices quickly Price limits can cause shortages, launch delays, or exits	Chosen 5. Stabilize & govern	high	Raise prices when supply falls.	—
Independent peer review with set-asides for high-risk ideas Government chooses which research gets funded	Chosen 1. Enactment & build	high	Keeps scientists, not politicians, choosing grants.	—
Measure outcomes by clinician type and adjust scope Quality concerns when non-physicians practice independently	Chosen 0. Preparation	high	Measure outcomes by clinician type.	—
Phase mandates in with workforce growth, funded in rates Staffing mandates raise costs and may close facilities	Chosen 5. Stabilize & govern	high	Mandates tighten with workforce growth.	—
Standardized needs assessment and tiered benefits Covering long-term care can pull unpaid family care into the paid system	Chosen 5. Stabilize & govern	high	Independent needs assessment.	—
Independent audits and few, simple measures Targets and quality metrics invite gaming	Chosen 5. Stabilize & govern	high	Few, audited measures.	—